Provider Demographics
NPI:1528375359
Name:NICHOLSON, BETTY JANE (LPN, RN)
Entity Type:Individual
Prefix:MS
First Name:BETTY
Middle Name:JANE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LPN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 S GORDON COOPER DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-9007
Mailing Address - Country:US
Mailing Address - Phone:405-395-9304
Mailing Address - Fax:405-395-9305
Practice Address - Street 1:2307 S GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9007
Practice Address - Country:US
Practice Address - Phone:405-395-9304
Practice Address - Fax:405-395-9305
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL 0058799164W00000X
OK102230163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse